Hyacinthe Kankeu Tchewonpi, a young researcher in health economics, recently defended his PhD thesis entitled “Four essays on the economics of informal payments for health care in Africa”, at Aix-Marseille University. HFA interviewed him. It gave us an opportunity to look at an important but hardly explored aspect of health financing in Africa: "petty corruption" in health facilities.
Your work focused on "petty corruption" (“under-the-table payment” or "informal payments"), a sort of "bureaucratic corruption", which refers to the fact that public officials, in this case health workers solicit bribes from patients. How big is the problem?
The extent of the problem varies greatly from one country to another. For example, when we look at the figures from Afrobarometer round 5 surveys for Mauritius and Botswana, less than 0.5% of individuals reported having had to pay unofficial fees in their health care facilities during the last 12 months. In these countries, the problem can be considered marginal to non-existent. In Morocco, Egypt, and Sierra Leone on the other hand, this figure rises to more than 50%. It is very worrying when one person in two using public health care services reports that they had to pay unofficial fees to access care. There are also “intermediate” countries. It should be noted that there is a strong correlation between under-the-table payments in health systems and the general level of corruption in the country. When looking at Transparency International's corruption perception index, it is clear that the "cleanest" countries in this ranking are also those which have low percentages of individuals reporting having to make informal payments in health facilities. We then understand that the health system does not evolve in a vacuum but is areflection of the country's environment in terms of corruption.
In the countries where this happens, what are the main consequences and, above all, who are the victims of this system?
If we look at the existing literature, we can mention several adverse effects e.g. on the quality of and access to care, but also on efficiency and equity. In terms of access to care, the existence of unofficial fees constitutes an additional financial barrier for patients. Poorer patients may even refrain from seeking care when they need it. In fact, one of the main findings of my thesis is that inAfrican countries, the poorest patients bear the heaviest burden as a result of these informal payments. As far as the quality of care is concerned, when health workers expect or want to force patient to pay them a bribe, they may provide them with care of lower quality compared to the standard, make them wait longer, create artificial shortages of medicines and other medical supplies, all to get the patient to fork out. Two studies (one qualitative and one quantitative) conducted in Tanzania clearly demonstrate this type of behavior among health workers. In terms of efficiency, the idea often developed in the literature, is that through informal payments, you do not put money in the right place. Sometimes staff will provide unnecessary care to obtain additional payment although the care is of no therapeutic benefit to the patient. Finally, one of the potential problems is that these informal payments can even demotivate health workers. Indeed, if in a health facility, only one type of care provider - for example doctors - benefits from these informal payments, other categories of staff - nurses, for example – can decide to put in less effort, be less involved or invest less time in optimal patient management. The qualitative study I mentioned earlier in Tanzania highlights this phenomenon with health workers feeling a form of injustice in the distribution of informal payments. These are some examples of the perverse effects of these kinds of payment on the health system.
In your thesis, you present some theoretical results quite paradoxical, as for the relationship between wages and informal payments. Can you explain us a bit how you reach your conclusion?
Via a theoretical model, I studied a utility function of a physician which depends, among other variables, on his formal / official remuneration, the level of informal payments he can get from patients, and the number of patients he sees over a certain period. In the literature and in the public debate, it is often suggested that an increase in wages would eradicate or at least reduce the problem of corruption. I have looked at three types of official remuneration: wages, found in most African countries; an output-based payment (the doctor receives a lump sum per patient seen over a certain period); and a mixed remuneration system. The analysis of the proposed economic model shows that, at the equilibrium, the level of informal payments is the highest with the system of salary . Moreover, in the case of salary, an increase in wages does not lead to a reduction in "petty corruption", but has rather the opposite effect. The explanation is that the increase in salary (only) generates negative incentives for the physician in terms of effort. To reduce his effort, the idea is to receive fewer patients. To achieve this, he will send them a negative signal by increasing the level of informal payments that he demands.
Conversely, with the output-based payment, I have found that an increase in the unit payment per patient leads to a reduction in the level of corruption. The explanation here is that the doctor has an incentive to increase his effort, since the unit payment introduces a price mechanism into the system. According to the well-known law of supply, when the price increases, the producer (the doctor in this case) increases his production (the number of patients received). To see more patients, the doctor will send them a positive signal by reducing the level of informal payments he demands, hence the observed effect.
However, in the end, and taking also into account the participation constraint of physicians (i.e. the attractiveness of each remuneration system for doctors), it is the mixed remuneration (a share of salary + a share output-based payment) that appears to be the most appropriate for the decision maker. It may therefore be useful to consider a revision of the remuneration methods for health personnel in our countries in order not only to adapt this remuneration to the cost of living, but also to better link it to their actual activity and effort.
This draws you closer to the Performance Based Financing (PBF) that is developing in Africa.
It is true that the second type of remuneration (output-based payment) of this theoretical model can be seen as a basic form of performance-based financing and it would be interesting to also look at quality in order to get closer to PBF approaches. In my analysis, and for the sake of simplicity, the quality of care was considered fixed and identical for all patients. I believe that this work is a first contribution that makes it possible to provide an a priori (theoretical) justification for the adoption of results-based financing / remuneration mechanisms. It may help support the advocacy of African experts who are trying to convince their governments or development partners to take these approaches into account when reforming health systems.
Your work is groundbreaking on several levels for trying to understand the various dimensions of the problem of informal payments in Africa. You show that the determinants of this phenomenon lie just as well on the supply as on the demand side. Based on this, what interventions could be put in place to reduce the share of informal payments in health systems in Africa?
Strictly speaking, each factor that I have identified in the thesis could be the object of an intervention. I think one of the first things is the need to improve the financial protection of patients, particularly the poorest when they seek care. Health insurance schemes or voucher systems may be an option. Another intervention could be at the level of working conditions in health facilities. I have also shown that problems such as absenteeism among health workers and stock-outs of medicines and other medical supplies are highly associated with the occurrence of informal payments.
Within a Health facility, when there is shortage of a good or a service, its ‘price’ rises and this can result in informal payments. When patients are faced with long waiting times, they tend to pay more for faster access to care. In this respect, one of the things that would be interesting to evaluate (since it is already adopted as a national policy in several of our countries, in particular in HIV care), is the effect of task shifting (having nurses carry out certain tasks normally attributed to doctors to overcome the problem of human resources shortages).
On the patient side, there is a lack of information about their rights and the actual tariff of services (official fees) in health facilities. Studies show that when tariffs are displayed in the doctor's office, in the waiting room or in the corridor, there is a significant reduction in the risk of informal payments. I also think it might be interesting to put in place a system for patients to report when they have paid unofficial fees and for strict enforcement of sanctions against wrongdoers. The fact that corrupt acts remain practically unsanctioned, in spite of legal and regulatory texts laying down sanctions, is also – and unfortunately – a factor which generally favors the existence and the expansion of this phenomenon in our countries. One could imagine a study where, in some health facilities, the awareness of patients about their entitlements is raised up through sensitization and other means; in others, one might put up a system in which corrupt acts can be reported and actually sanctioned. After a certain time, these two strategies could be compared to a third group of facilities without any intervention.
What further research are you planning?
In general, the idea is to continue contributing to enrich the literature on the issue of informal payments in African health systems. In the short term, I plan to look at the link between informal payments and quality of care. According to qualitative studies, one of the main reasons why patients pay bribes is their desire to get better care. . I will therefore try to answer the question whether patients who pay unofficial fees really obtain care of better quality from health workers.
And now for something completely different... You just got a PhD in economics from a prestigious university. Some of our readers would like to follow your example. Do you have some advice for African experts who would like to start a PhD?
I would say that the first thing is to have an idea about a topic. When you start to look for a thesis advisor, it’s good to already have an idea of research topic that really interests you. Given that the time spent on your thesis is relatively long (3-4 years), it will very quickly become boring if you do not have a personal or particular interest in the work you are doing. Next, try to identify professors or researchers who might be interested in accompanying the proposed work. You can do this by comparing, for example, their research interests with the topic that you have in mind. Another important aspect is to ask what type of doctoral programme is suitable to your particular situation. I think that it’s easiest for those wishing to write a thesis, while pursuing their professional activity, to choose a thesis topic related to their daily work. Once you have found a supervisor, you can evaluate the various possibilities for initiating the thesis with him/her (programme choice, administrative procedures, funding, work planning, etc.). Finally, I strongly encourage those who want to undertake a PhD but who have doubts, to discuss it for example with the academics who are members of this community of practice.
